Incarcerated Bochdalek Hernia in Adults.

In this case report, the diagnostic challenge and emergency management of a Bochdalek hernia in adults in Mexico are outlined. This case report can help the medical community to consider the clinical presentation in adults and the importance of early diagnosis and management. We present a 57-year-old female patient with a history of arterial hypertension who, following a bout of abdominal pain, was diagnosed with a Bochdalek hernia. Following emergency surgery, there was an increase in intra-abdominal pressure, which was continuously monitored due to the possibility of compartment syndrome, potentially necessitating a second emergency surgery.

Preferences and Demand for Mosquito Control among Dengue-Endemic Communities in Peñuelas, Puerto Rico: An Application of the Best-Worst Choice Model.

Aedes aegypti is the primary vector of dengue virus and threatens 3.9 billion people living in many tropical and subtropical countries. Prevention and reduction of dengue and other Aedes-borne viruses, including Zika and chikungunya, requires control of mosquito populations. Community mobilization and input are essential components of vector control efforts. Many vector control campaigns do not engage communities prior to implementation, leading to program failure. Those that do often conduct basic knowledge, attitude, and practice surveys that are not designed to explicitly elicit preferences. Here, we applied a novel stated preference elicitation tool, best-worst choice, to understand preferences, willingness to participate, and willingness to pay for mosquito control in dengue-endemic communities of Peñuelas, Puerto Rico. Findings revealed that the community preferred mosquito control programs that are 1) applied at the neighborhood level, 2) implemented by the local government, and 3) focused specifically on reducing disease transmission (e.g., dengue) instead of mosquito nuisance. Programs targeting the reduction of disease transmission and higher educational level of participants increased willingness to participate. Participants were willing to pay an average of $72 annually to have a program targeting the reduction of diseases such as dengue. This study serves as a model to engage communities in the design of mosquito control programs and improve stakeholders' decision-making.

How deregulation, drought and increasing fire impact Amazonian biodiversity.

Biodiversity contributes to the ecological and climatic stability of the Amazon Basin1,2, but is increasingly threatened by deforestation and fire3,4. Here we quantify these impacts over the past two decades using remote-sensing estimates of fire and deforestation and comprehensive range estimates of 11,514 plant species and 3,079 vertebrate species in the Amazon. Deforestation has led to large amounts of habitat loss, and fires further exacerbate this already substantial impact on Amazonian biodiversity. Since 2001, 103,079-189,755 km2 of Amazon rainforest has been impacted by fires, potentially impacting the ranges of 77.3-85.2% of species that are listed as threatened in this region5. The impacts of fire on the ranges of species in Amazonia could be as high as 64%, and greater impacts are typically associated with species that have restricted ranges. We find close associations between forest policy, fire-impacted forest area and their potential impacts on biodiversity. In Brazil, forest policies that were initiated in the mid-2000s corresponded to reduced rates of burning. However, relaxed enforcement of these policies in 2019 has seemingly begun to reverse this trend: approximately 4,253-10,343 km2 of forest has been impacted by fire, leading to some of the most severe potential impacts on biodiversity since 2009. These results highlight the critical role of policy enforcement in the preservation of biodiversity in the Amazon.

Recognizing the insurance value of resilience: Evidence from a forest restoration policy in the southeastern U.S.

The long-term supply of ecosystem services is dependent on properly functioning ecosystems and their susceptibility to natural and anthropogenic disturbances such as climate change and urbanization, as they can alter ecosystem structure and function. Forest function is not static, but rather a risky asset that fluctuates and can decrease as a result of forest disturbance. Therefore, concepts such as resilience and insurance value as well effective policy formulation, management, and restoration are key to maintaining these benefits. This study estimates the insurance value that the public places on a policy that promotes restoration for increased resilience and ecosystem services using binary choice (BC) and best-worst scaling (BWS) models to estimate willingness to pay (WTP) and to vote for the restoration of longleaf pine (LLP) forests in the southeastern United States. Our BWS findings indicate that respondents seemed to only prefer programs with low risk of forest damage and lower monthly costs, while BC models show that low and moderate risk programs increased the likelihood of voting for them and that excellent wildlife habitat was also highly valued by our respondents. Positive attitudes towards the environment also positively influence voting for forest restoration programs. Findings contribute to an emerging body of literature on social-ecological systems and how the voting public conceptualizes trade-offs among ecosystem services, insurance value, and resilience. Results may help assess the use and incorporation of concepts such as resilience, ecosystem services, and insurance value in restoration, environmental, fire management, and climate change-related policy instruments and programs.

Asma: uso adecuado de dispositivos para inhalación / Asthma: correct use of inhalation drug-delivery devices

Resumen La terapia inhalada se considera la piedra angular del manejo del asma. Sin embargo, a pesar de ser la forma ideal de administración de estos medicamentos, solamente el 70% de los pacientes cumple el tratamiento adecuadamente y sólo del 39 al 67% de los médicos conocen y pueden explicar de forma adecuada las distintas técnicas de inhalación. La terapia inhalada tiene características muy particulares. El depósito pulmonar de un medicamento inhalado a través del tracto respiratorio es más complejo que cuando se administra por vía oral, y varía dependiendo de varios factores, tanto inherentes al medicamento como a la forma de administrarlo. Para que la terapia inhalada sea exitosa, se requiere que se generen partículas del medicamento de un tamaño apropiado que penetren más allá de la orofaringe y la laringe, y que puedan depositarse en los pulmones. Existen múltiples dispositivos para la administración de medicamentos en la vía respiratoria baja. Cada uno ha probado tener una eficacia similar, siempre y cuando se utilicen con la técnica correcta. La decisión para su uso se realiza con base en la edad del paciente, la capacidad de coordinar entre la inhalación y la activación del dispositivo y la presencia de síntomas agudos. La elección del dispositivo a utilizar siempre deberá hacerse de forma conjunta, evaluando pros y contras de cada uno de los dispositivos y siempre de forma individualizada.

Abstract Inhaled therapy is considered the cornerstone of asthma treatment. However, despite being the ideal form of drug delivery, it is recognized that only 70% of patients have an adequate attachment to their treatment and only 39-67% of physicians can explain the optimal inhaler technique. Inhaled therapy has very specific characteristics. Pulmonary deposit of an inhaled medication through the respiratory tract is more complex than when administered orally and depends on several factors inherent to both the medication and the administration. For successful inhaled therapy, the drug needs to be converted into particles of an appropriate size, which can enter beyond the oropharynx and larynx, and be deposited in the lungs. There are multiple devices for the administration of drugs in the lower respiratory tract, each one with a similar efficacy as long as it is used with the correct technique. The decision of which device should be used is made based on the age of the patient, the ability to coordinate between the inhalation and activation of the device, and the presence of acute symptoms. The choice of the device must be evaluated individually.

Asma: uso adecuado de dispositivos para inhalación.

Inhaled therapy is considered the cornerstone of asthma treatment. However, despite being the ideal form of drug delivery, it is recognized that only 70% of patients have an adequate attachment to their treatment and only 39-67% of physicians can explain the optimal inhaler technique. Inhaled therapy has very specific characteristics. Pulmonary deposit of an inhaled medication through the respiratory tract is more complex than when administered orally and depends on several factors inherent to both the medication and the administration. For successful inhaled therapy, the drug needs to be converted into particles of an appropriate size, which can enter beyond the oropharynx and larynx, and be deposited in the lungs. There are multiple devices for the administration of drugs in the lower respiratory tract, each one with a similar efficacy as long as it is used with the correct technique. The decision of which device should be used is made based on the age of the patient, the ability to coordinate between the inhalation and activation of the device, and the presence of acute symptoms. The choice of the device must be evaluated individually.

La terapia inhalada se considera la piedra angular del manejo del asma. Sin embargo, a pesar de ser la forma ideal de administración de estos medicamentos, solamente el 70% de los pacientes cumple el tratamiento adecuadamente y sólo del 39 al 67% de los médicos conocen y pueden explicar de forma adecuada las distintas técnicas de inhalación. La terapia inhalada tiene características muy particulares. El depósito pulmonar de un medicamento inhalado a través del tracto respiratorio es más complejo que cuando se administra por vía oral, y varía dependiendo de varios factores, tanto inherentes al medicamento como a la forma de administrarlo. Para que la terapia inhalada sea exitosa, se requiere que se generen partículas del medicamento de un tamaño apropiado que penetren más allá de la orofaringe y la laringe, y que puedan depositarse en los pulmones. Existen múltiples dispositivos para la administración de medicamentos en la vía respiratoria baja. Cada uno ha probado tener una eficacia similar, siempre y cuando se utilicen con la técnica correcta. La decisión para su uso se realiza con base en la edad del paciente, la capacidad de coordinar entre la inhalación y la activación del dispositivo y la presencia de síntomas agudos. La elección del dispositivo a utilizar siempre deberá hacerse de forma conjunta, evaluando pros y contras de cada uno de los dispositivos y siempre de forma individualizada.

Small-scale forestry and carbon offset markets: An empirical study of Vermont Current Use forest landowner willingness to accept carbon credit programs.

This study investigates the preferences of small forest landowners regarding forest carbon credit programs while documenting characteristics of potentially successful frameworks. We designed hypothetical carbon credit programs with aggregated carbon offset projects and requirements of existing voluntary and compliance protocols in mind. We administered a mail survey to 992 forest landowners in Vermont's Current Use Program utilizing best-worst choice, a novel preference elicitation technique, to elicit their preferences about these programs. We found that small forest landowners see revenue as the most important factor in a carbon credit program and the duration of the program as the least important factor. Landowners reported that shorter program duration, higher revenue, and lower withdrawal penalties positively impact their willingness to accept forest carbon credit programs. Notably, our study includes carbon credit program implementer as a key program attribute, allowing us to quantify landowners' tradeoffs between non-profit, for-profit, and government organizations. Overall, we found that landowners significantly prefer working with a non-profit organization. Based on monetary estimates of willingness-to-accept compensation, our results suggest that aggregated forest carbon offset projects incorporating small forest landowners could be piloted successfully in Vermont by non-profit organizations while maintaining relatively strict guidelines of existing carbon offset protocols.

One Thousand Pediatric Liver Transplants During Thirty Years: Lessons Learned.

BACKGROUND: Pediatric liver transplantation (pLTx) has been the standard of care for children with liver failure since the 1980s. This study examined the world's largest single-center experience and aimed to identify unique preoperative predictors of early graft and patient survival for primary transplantation (1°-pLTx) and retransplantation (Re-pLTx). STUDY DESIGN: We conducted an IRB-approved, retrospective study of all consecutive, isolated pLTx patients 18 years of age or younger. Twenty-eight demographic, laboratory, and perioperative variables were analyzed as potential outcome predictors. Univariate and multivariate analyses were performed using log-rank test and Cox's proportional hazards model. RESULTS: There were 806 children who received 1,016 isolated pLTx between February1984 and June 2017. Median follow-up was 12 years. Leading indications for pLTx were cholestatic liver disease (40%), re-pLTx (21%), and fulminant hepatic failure (14%). Seventy-three percent received cadaveric whole grafts. Overall graft and patient survival rates at 0.5, 1, 5, 10, and 20 years were: 76%, 73%, 67%, 63%, 53%, and 87%, 86%, 81%, 78%, 69%, respectively. Relative to 1°-pLTx, re-pLTx recipients were significantly older, larger, with worse renal function, and more likely to be awaiting pLTx in an ICU. Independent significant predictors of graft survival for 1°-pLTx included weight, transplantation era, and renal replacement therapy; for re-pLTx, warm ischemia time and time between 1°-pLTx and re-pLTx. Independent significant predictors of patient survival were renal function, mechanical ventilation, and etiology of liver disease. CONCLUSIONS: This is the largest reported single-center experience of pLTx with substantial follow-up time and a large re-pLTx experience. Important transplant predictors of graft survival include weight, renal function, modern era, warm ischemia time, and time between primary transplantation and re-pLTx. Renal function, mechanical ventilation, and underlying cause of liver disease affect patient survival. Awareness of these factors can help in the decision making for children requiring pLTx.

Expected Timber-Based Economic Impacts of a Wood-Boring Beetle (Acanthotomicus Sp.) That Kills American Sweetgum.

American sweetgum trees (Liquidambar styraciflua L. [Altingiaceae]) in China are being killed by a newly discovered wood-boring beetle "sweetgum inscriber" (Acanthotomicus sp.). It has not been detected in the United States yet, but given the extent of trade with Asian countries, eventual arrival of this beetle is a serious concern. The American sweetgum is one of the main hardwood species in the southern United States, and provides several economic and ecological benefits to society. We present the first economic analysis of the potential damage from sweetgum inscriber (SI) to timber-based land values in the southern United States. We modeled economic impacts for a range of feasible SI arrival rates that reflect policy interventions: 1) no efforts to prevent arrival (scenario A, once every 14 and 25 yr), 2) partial prevention by complying with ISPM 15 standards (scenario B, once every 33 and 100 yr), and 3) total prevention of arrival (scenario C, zero transmission of SI). Our results indicated much lower land values for sweetgum plantations without the prevention on SI establishment (scenario A, US$1,843-US$4,383 ha-1) compared with partial prevention (scenario B, US$5,426-US$8,050 ha-1) and total eradication of SI (scenario C, US$9,825). Across the region, upper bound timber-based economic losses to plantation owners is US$151.9 million (US$4.6 million annually)-an estimate that can help inform policy decisions.

Pre-invasion economic assessment of invasive species prevention: A putative ambrosia beetle in Southeastern loblolly pine forests.

Invasive wood borers vectoring pathogenic fungi have nearly exterminated several North American tree species, and it is unclear whether landscape dominant trees, such as pines, will face similar threats in the future. This paper explores the economic impacts of a hypothetical arrival of a destructive ambrosia beetle "X" (Coleoptera: Curculionidae) that infests loblolly pine (Pinus taeda L.) forests in the Southeastern United States. We develop an economic framework for pre-invasion assessment that incorporates fluctuating economic and environmental conditions for a representative loblolly pine stand and biological assumptions from the ongoing laurel wilt epidemic. Assuming an initial annual probability of arrival of a pine infesting ambrosia beetle to be between 0.04 and 0.07, we determine that, on average, the timber economic benefits for a forest landowner are $5325.3 ha-1, with a harvest time of 17.8 years. Our results indicate that an increase in enforcement consistent with an international phytosanitary standard that partially prevents the arrival of ambrosia beetles (30% arrival reduction) would have a strong, positive impact for forest landowners. On average, economic revenues increase to $6116.4 ha-1 and the harvest age is extended to 19 years. On average, the economic losses for forest landowners with no control of ambrosia beetle X would be $791 ha-1, with a harvest time reduction of 1.2 years. The upper-bound regional cost savings from pine-dominated forestry would be roughly $4.6 billion dollars if invasion preventative measures are in place. These benefits vastly outweigh the cost of programs that reduce the expected arrival of exotic ambrosia beetles.

What's the hold up? Factors contributing to delays in discharge of trauma patients after medical clearance.

BACKGROUND: One area of potential savings in healthcare spending is the identification of nonmedical delays in discharge. The purpose of this study was to identify factors associated with discharge delays. METHODS: All patients admitted to our trauma center over a 1-year period with a social work consult were retrospectively evaluated to identify delays in discharge after medical clearance. RESULTS: Over half of our patients experienced a delay in discharge. Age was not associated with delay in discharge. Higher injury severity score, intensive care unit admission, and hospital length of stay greater than 1 week were all associated with increased delays in discharge. Other factors such as disposition to a rehabilitation/nursing facility and mechanism of injury were also associated with a nonmedical delay. CONCLUSIONS: We have identified nonmedical factors associated with delays in discharge. Strategies using these data could be used to improve discharge planning and may help decrease healthcare costs.